Molecular mechanism of acute ammonia toxicity and of its prevention by L-carnitine

Successful heart transplantation in a patient with adolescent-onset dilated cardiomyopathy secondary to propionic acidaemia: a case report

BACKGROUND

Propionic acidaemia (PA) is an autosomal recessive disorder resulting from deficiency of propionyl-CoA carboxylase, a mitochondrial enzyme that metabolizes propionyl-CoA. Generally, patients with PA develop symptoms in the neonatal period due to protein intake through breastfeeding; however, late-onset PA with atypical symptoms, including cardiomyopathy, has been recently reported.

CASE SUMMARY

We present the case of a 25-year-old male with late-onset PA complicated by advanced heart failure (HF) due to isolated secondary dilated cardiomyopathy, who required left ventricular assist device (LVAD) implantation and finally underwent heart transplantation (HTx). Initially, the patient developed HF at the age of 16 and was diagnosed with mitochondrial cardiomyopathy. Due to refractory HF, he underwent an LVAD implantation and was scheduled for HTx. During the preoperative period for HTx, the patient suffered from sepsis due to the worsening of LVAD driveline exit-site infection complicated by overt metabolic acidosis, finally leading to the diagnosis of late-onset PA. After this diagnosis, adequate nutritional interventions were introduced, and the cardiac function was partially restored enough for him to be weaned-off LVAD; however, the patient became inotrope dependent and underwent HTx. The post-HTx course was uneventful with special nutritional management, and he has experienced no adverse metabolic events in the past 3 years.

DISCUSSION

Late-onset PA can cause isolated adult-onset cardiomyopathy, and LVAD or HTx should be considered when PA is complicated by advanced HF and is unresponsive to conventional medical therapies.

Pathophysiology of propionic and methylmalonic acidemias. Part 1: Complications

Over the last decades, advances in clinical care for patients suffering from propionic acidemia (PA) and isolated methylmalonic acidemia (MMA) have resulted in improved survival. These advances were possible thanks to new pathophysiological insights. However, patients may still suffer from devastating complications which largely determine the unsatisfying overall outcome. To optimize our treatment strategies, better insight in the pathophysiology of complications is needed. Here, we perform a systematic data-analysis of cohort studies and case-reports on PA and MMA. For each of the prevalent and rare complications, we summarize the current hypotheses and evidence for the underlying pathophysiology of that complication. A common hypothesis on pathophysiology of many of these complications is that mitochondrial impairment plays a major role. Assuming that complications in which mitochondrial impairment may play a role are overrepresented in monogenic mitochondrial diseases and, conversely, that complications in which mitochondrial impairment does not play a role are underrepresented in mitochondrial disease, we studied the occurrence of the complications in PA and MMA in mitochondrial and other monogenic diseases, using data provided by the Human Phenotype Ontology. Lastly, we combined this with evidence from literature to draw conclusions on the possible role of mitochondrial impairment in each complication. Altogether, this review provides a comprehensive overview on what we, to date, do and do not understand about pathophysiology of complications occurring in PA and MMA and about the role of mitochondrial impairment herein.

Neurotoxicity of Ammonia

Abnormal liver function has dramatic effects on brain functions. Hyperammonemia interferes profoundly with brain metabolism, astrocyte volume regulation, and in particular mitochondrial functions. Gene expression in the brain and excitatory and inhibitory neurotransmission circuits are also affected. Experiments with a number of pertinent animal models have revealed several potential mechanisms which could underlie the pathological phenomena occurring in hepatic encephalopathy.

Efficacy of L-carnitine in reducing hyperammonaemia and improving neuropsychological test performance in patients with hepatic cirrhosis : results of a randomised trial

OBJECTIVES

To determine the efficacy of L-carnitine in reducing hyperammonaemia and improving neuropsychological performance in patients with hepatic cirrhosis and subclinical hepatic encephalopathy (SHE).

DESIGN

Randomised, parallel group, controlled trial.

PATIENTS AND METHODS

The study enrolled 31 patients with hepatic cirrhosis resulting from hepatitis C and/or hepatitis B, alcohol abuse and other causes. Patients randomised to active treatment, received oral L-carnitine 6 g/day in two divided doses for 4 weeks. Diagnosis of SHE was based on psychometric tests (subtests of the Wechsler Adult Intelligence Scale-Revised and the Halstead-Reitan Neuropsychological Test Battery) carried out at beginning and end of study. Serum ammonia levels were measured before treatment and weekly thereafter.

RESULTS

A total of 27 patients completed the study. Sixteen patients received L-carnitine and 11 served as controls (no treatment). L-carnitine caused rapid and significant reductions in ammonia levels, sustained over the 4-week treatment period (mean reductions 60.1 and 1.4 (μmol/L in the treated and control groups, respectively). Normal ammonia levels were attained in 14 of 16 patients receiving L-carnitine. Based on psychometric test results, seven patients (43.7%) in the L-carnitine group and five (45.5%) in the control group had SHE at baseline. L-carnitine treatment for 4 weeks caused a net overall improvement in psychometric test results compared with controls. No clinically significant adverse events were reported and all patients receiving L-carnitine reported subjective improvements in their condition.

CONCLUSIONS

RESULTS of this preliminary study indicate that L-carnitine reduces hyperammonaemia and improves the clinical symptoms of SHE in patients with hepatic cirrhosis.

The physiology and toxicology of salmonid eggs and larvae in relation to water quality criteria

The purpose of this review is to collate physiological knowledge on salmonid eggs and larvae in relation to water quality criteria. Salmonid genera reviewed include Coregonus, Thymallus, Salvelinus, Salmo, and Oncorhynchus spp. When physiological data for salmonids are lacking, the zebrafish and medaka models are included. The primary focus is on the underlying mechanisms involved in the hydro-mineral, thermal, and respiratory biology with an extended section on the xenobiotic toxicology of the early stages. Past and present data reveal that the eggs of salmonids are among the largest shed by any broadcast spawning teleost. Once ovulated, the physicochemical properties of the ovarian fluid provide temporary protection from external perturbations and maintain the eggs in good physiological condition until spawning. Following fertilisation and during early development the major structures protecting the embryo from poor water quality are the vitelline membrane, the enveloping layer and the chorion. The vitelline membrane is one of the least permeable membranes known, while the semi-permeable chorion provides both physical and chemical defense against metals, pathogens, and xenobiotic chemicals. In part these structures explain the lower sensitivity of the eggs to chemical imbalance compared to the larvae, however the lower metabolic rate and the chronology of gene expression and translational control suggest that developmental competence also plays a decisive role. In addition, maternal effect genes provide a defense potential until the mid-blastula transition. The transition between maternal effect genes and zygotic genes is a critical period for the embryo. The perivitelline fluids are an important trap for cations, but are also the major barrier to diffusion of gases and solutes. Acidic environmental pH interferes with acid-base and hydromineral balance but also increases the risk of aluminium and heavy metal intoxication. These risks are ameliorated somewhat by the presence of ambient humic acid. High temperatures during development may be teratogenic, cause sexual bias, or long-term effects on muscle cellularity. Xenobiotics cause inhibition of neural acetylcholine esterase and carboxylases and disrupt the normal signalling pathways of hormones by binding to relevant receptors and mimicking their actions. A complex suite of genes is activated in response to environmental or parentally transmitted xenobiotics. The primary defense mechanism in embryos involves resistance to uptake but later biotransformation via the aryl hydrocarbon receptor (AHR)-mediated activation of members of the cytochrome mixed-function mono-oxygenase superfamily (CYP1A, CYP2B, and CYP3A) and subsequent glucuronidation or glutathionation. Due to the number of duplicate or triplicate genes coding for intermediates in the signalling pathways, and cross-talk between nuclear orphan receptors and steroid hormone receptors, a large number of complications arise in response to xenobiotic intoxicaton. One such syndrome, known as blue-sac disease causes an anaphylactoid response in hatched larvae due to increased permeability in the vascular endothelium that coincides with AHR-mediated CYP induction. Early embryos also respond to such xenobiotic insults, but apparently have an immature translational control for expression of CYP proteins, which coincides with a lack of excretory organs necessary for the end-point of biotransformation. Other syndromes (M74 and Cayuga) are now associated with thiamine deficiency. Where possible guidelines for water quality criteria are suggested.

L-carnitine protects against glutamate- and kainic acid-induced neurotoxicity in cerebellar granular cell culture of rats

Glutamate mediated intracellular calcium accumulation and free radical generation are thought to be major mechanisms that contribute to cell death in hypoxic-ischemic brain injury. For this reason, various glutamate receptor antagonists and antioxidants have been investigated for their therapeutic potential. To assess whether L-carnitine, a possible antioxidant, is able to prevent glutamate- and kainic acid (KA)-induced neurotoxicity. Glutamate (10(-7) M) and one of its receptor agonists, KA (10(-4) M) were administered to cerebellar granular cell cultures that were prepared from 1-day-old Sprague-Dawley rats. The neuroprotective effect of L-carnitine was examined. L-carnitine at doses of 10(-6), 10(-5), 10(-4), 10(-3) M was applied to culture flasks. L-carnitine at doses of 10(-4) and 10(-3) M significantly blocked glutamate-induced neurotoxicity. 10(-4) M dose of L-carnitine proved to be more effective than 10(-3)M. L-carnitine also blocked KA-induced neurotoxicity only at the dose of 10(-4) M. 10(-4) M L-carnitine, the most effective dose in both glutamate- and KA-induced neurotoxicity, decreased glutamate-induced neuronal cell death from 36.14+/-2.95% to 17.59+/-2.25%; (P<0.001) and KA-induced neuronal cell death from 21.4+/-0.41 to 13.4+/-1.38%; (P<0.001). The present study demonstrates that L-carnitine protects against glutamate- and KA-induced neurotoxicity. Protective effect of L-carnitine may result from its antioxidant activity because free radical generation is a common result in either glutamate- or KA-induced neurotoxicity. L-carnitine merits further investigation as a therapeutic option in hypoxic-ischemic brain injury of newborn.

Chronic and acute ammonia toxicity in mudskippers, Periophthalmodon schlosseri and Boleophthalmus boddaerti: brain ammonia and glutamine contents, and effects of methionine sulfoximine and MK801

The objective of this study was to elucidate if chronic and acute ammonia intoxication in mudskippers, Periophthalmodon schlosseri and Boleophthalmus boddaerti, were associated with high levels of ammonia and/or glutamine in their brains, and if acute ammonia intoxication could be prevented by the administration of methionine sulfoximine [MSO; an inhibitor of glutamine synthetase (GS)] or MK801 [an antagonist of N-methyl D-aspartate type glutamate (NMDA) receptors]. For P. schlosseri and B. boddaerti exposed to sublethal concentrations (100 and 8 mmol l(-1) NH4Cl, respectively, at pH 7.0) of environmental ammonia for 4 days, brain ammonia contents increased drastically during the first 24 h, and they reached 18 and 14.5 micromol g(-1), respectively, at hour 96. Simultaneously, there were increases in brain glutamine contents, but brain glutamate contents were unchanged. Because glutamine accumulated to exceptionally high levels in brains of P. schlosseri (29.8 micromol g(-1)) and B. boddaerti (12.1 micromol g(-1)) without causing death, it can be concluded that these two mudskippers could ameliorate those problems associated with glutamine synthesis and accumulation as observed in patients suffering from hyperammonemia. P. schlosseri and B. boddaerti could tolerate high doses of ammonium acetate (CH3COONH4) injected into their peritoneal cavities, with 24 h LC50 of 15.6 and 12.3 micromol g(-1) fish, respectively. After the injection with a sublethal dose of CH3COONH4 (8 micromol g(-1) fish), there were significant increases in ammonia (5.11 and 8.36 micromol g(-1), respectively) and glutamine (4.22 and 3.54 micromol g(-1), respectively) levels in their brains at hour 0.5, but these levels returned to normal at hour 24. By contrast, for P. schlosseri and B. boddaerti that succumbed within 15-50 min to a dose of CH3COONH4 (15 and 12 micromol g(-1) fish, respectively) close to the LC50 values, the ammonia contents in the brains reached much higher levels (12.8 and 14.9 micromol g(-1), respectively), while the glutamine level remained relatively low (3.93 and 2.67 micromol g(-1), respectively). Thus, glutamine synthesis and accumulation in the brain was not the major cause of death in these two mudskippers confronted with acute ammonia toxicity. Indeed, MSO, at a dosage (100 microg g(-1) fish) protective for rats, did not protect B. boddaerti against acute ammonia toxicity, although it was an inhibitor of GS activities from the brains of both mudskippers. In the case of P. schlosseri, MSO only prolonged the time to death but did not reduce the mortality rate (100%). In addition, MK801 (2 microg g(-1) fish) had no protective effect on P. schlosseri and B. boddaerti injected with a lethal dose of CH3COONH4, indicating that activation of NMDA receptors was not the major cause of death during acute ammonia intoxication. Thus, it can be concluded that there are major differences in mechanisms of chronic and acute ammonia toxicity between brains of these two mudskippers and mammalian brains.

Ammonia-mediated LTP inhibition: effects of NMDA receptor antagonists and L-carnitine

Because hyperammonemia is thought to contribute to the pathogenesis of hepatic encephalopathy, we examined the effects of ammonia on ATP levels, neuronal morphology, and synaptic function in rat hippocampal slices. Although ammonia did not alter ATP levels supported by 10 mM glucose, ammonia significantly depressed ATP levels in the presence of 3.3 mM glucose or 10 mM pyruvate, suggesting effects on respiratory energy metabolism. Ammonia also impaired synaptic function and neuronal integrity sustained by pyruvate. In 10 mM glucose, ammonia inhibited the induction and maintenance of long-term potentiation (LTP) in a concentration-dependent fashion. These inhibitory effects of ammonia were overcome by L-carnitine. DL-APV, an antagonist of NMDA receptors, also diminished the effects of ammonia on ATP levels and LTP induction, indicating that ammonia impairs neuronal function via altered metabolism and untimely NMDA receptor activation. These results suggest that L-carnitine and NMDA receptor antagonists have the potential to preserve neuronal function during hyperammonemia.

Defences against ammonia toxicity in tropical air-breathing fishes exposed to high concentrations of environmental ammonia: a review

In the tropics, air-breathing fishes can be exposed to environmental ammonia when stranded in puddles of water during the dry season, during a stay inside a burrow, or after agricultural fertilization. At low concentrations of environmental ammonia, NH(3) excretion is impeded, as in aerial exposure, leading to the accumulation of endogenous ammonia. At high concentrations of environmental ammonia, which results in a reversed NH(3) partial pressure gradient (DeltaP(NH3)), there is retention of endogenous ammonia and uptake of exogenous ammonia. In this review, several tropical air-breathing fishes (giant mudskipper, African catfish, oriental weatherloach, swamp eel, four-eyed sleeper, abehaze and slender African lungfish), which can tolerate high environmental ammonia exposure, are used as examples to demonstrate how eight different adaptations can be involved in defence against ammonia toxicity. Four of these adaptations deal with ammonia toxicity at branchial and/or epithelial surfaces: (1) active excretion of NH(4)(+); (2) lowering of environmental pH; (3) low NH(3) permeability of epithelial surfaces; and (4) volatilization of NH(3), while another four adaptations ameliorate ammonia toxicity at the cellular and subcellular levels: (5) high tolerance of ammonia at the cellular and subcellular levels; (6) reduction in ammonia production; (7) glutamine synthesis; and (8) urea synthesis. The responses of tropical air-breathing fishes to high environmental ammonia are determined apparently by behavioural adaptations and the nature of their natural environments.

Effects of peritoneal injection of NH4HCO3 on nitrogen excretion and metabolism in the swamp eel Monopterus albus-- increased ammonia excretion with an induction of glutamine synthetase activity

Monopterus albus has to deal with high environmental ammonia concentrations during dry seasons and agricultural fertilization in rice fields. In this study, NH4HCO3 (10 micromol per g fish) was injected into the peritoneal cavity of M. albus, raising the level of ammonia in the body, in order to elucidate the strategies involved in defense against the toxicity of exogenous ammonia. During the subsequent 24 h after NH4HCO3 injection, there was a significant increase in the ammonia excretion rate, which indicates that the main strategy adopted by M. albus was to remove the majority of the exogenous ammonia through enhanced ammonia excretion. Exogenous ammonia was not detoxified into urea for excretion or accumulation. Six hours post-injection of NH4HCO3, ammonia content in the tissues built up significantly, especially in the brain, which suggests that M. albus had high tolerance of ammonia toxicity at the cellular and sub-cellular levels. By hour 12 post-injection, there were significant increases in the activities of glutamine synthetase in the muscle, liver, and gut, accompanied by significant increases in glutamine contents in the muscle and the liver. There was also a significant increase in the glutamine content in the brain at hour 6 post-injection of NH4HCO3. These results confirm the capability of M. albus to detoxify ammonia through glutamine synthesis. Overall, injection of NH4HCO3 had only minor effects on the contents of FAAs, other than glutamine, in tissues of M. albus because the majority (70%) of the injected ammonia was excreted within the 24-h period.

Ammonia potentiates methylmalonic acid-induced convulsions and TBARS production

Hyperammonemia is a common finding in children with methylmalonic acidemia, an inherited metabolic disease characterized by mental retardation, convulsions, and accumulation of methylmalonic acid (MMA). Although it has been suggested that MMA induces convulsions through succinate dehydrogenase (SDH) inhibition, very little is known about the contribution of hyperammonemia to the development of convulsions in these patients. In the present study we investigated the effects of ammonium ions on the convulsant action of MMA, MMA-induced inhibition of striatal succinate dehydrogenase, and the striatal content of thiobarbituric acid-reactive substances (TBARS). Adult rats were injected with ammonium acetate (1.5 mmol/kg, sc) or sodium acetate (1.5 mmol/kg, sc), followed 5 min later by buffered MMA (3 micromol/microl) or NaCl (4.5 micromol/microl) injected into the striatum. The animals were observed in an open field for the appearance of convulsive episodes. After 30 min of behavioral evaluation, the animals were sacrificed and had their striatal TBARS content measured. Ammonium acetate pretreatment caused no behavioral effects per se, but potentiated MMA-induced convulsions and increased basal TBARS content and MMA-induced TBARS production in the striatum. Ammonium chloride had no effect on basal succinate dehydrogenase activity and did not alter MMA-induced inhibition of SDH in vitro. These results suggest that ammonia potentiates MMA-induced behavioral effects through a mechanism that does not involve further succinate dehydrogenase inhibition, but may involve facilitation of MMA-induced oxidative damage and provide evidence that ammonia and MMA may have mutually additive toxicity.

The swamp eel Monopterus albus reduces endogenous ammonia production and detoxifies ammonia to glutamine during 144 h of aerial exposure

The swamp eel Monopterus albus inhabits muddy ponds, swamps, canals and rice fields, where it can burrow within the moist earth during the dry summer season, thus surviving for long periods without water. This study aimed to elucidate the strategies adopted by M. albus to defend against endogenous ammonia toxicity when kept out of water for 144 h (6 days). Like any other fish, M. albus has difficulties in excreting ammonia during aerial exposure. In fact, the rates of ammonia and urea excretions decreased significantly in specimens throughout the 144 h of aerial exposure. At 144 h, the ammonia and urea excretion rates decreased to 20% and 25%, respectively, of the corresponding control values. Consequently, ammonia accumulated to high levels in the tissues and plasma of the experimental specimens. Apparently, M. albus has developed relatively higher ammonia tolerance at the cellular and subcellular levels compared with many other teleost fish. Since the urea concentration in the tissues of specimens exposed to air remained low, urea synthesis was apparently not adopted as a strategy to detoxify endogenous ammonia during 144 h of aerial exposure. Instead, ammonia produced through amino acid catabolism was detoxified to glutamine, leading to the accumulation of glutamine in the body during the first 72 h of aerial exposure. Complementing the increased glutamine formation was a significant increase in glutamine synthetase activity in the liver of specimens exposed to air for 144 h. Formation of glutamine is energetically expensive. It is probably because M. albus remained relatively inactive on land that the reduction in energy demand for locomotory activity facilitated its exploitation of glutamine formation to detoxify endogenous ammonia. There was a slight decrease in the glutamine level in the body of the experimental animals between 72 h and 144 h of aerial exposure, which indicates that glutamine might not be the end product of nitrogen metabolism. In addition, these results suggest that suppression of endogenous ammonia production, possibly through reductions in proteolysis and amino acid catabolism, acts as the major strategy to avoid ammonia intoxication in specimens exposed to air for >/=72 h. It is concluded that glutamine formation and reduction in ammonia production together served as effective strategies to avoid the excessive accumulation of ammonia in the body of M. albus during 144 h of aerial exposure. However, these strategies might not be adequate to sustain the survival of M. albus in the mud for longer periods during drought because ammonia and glutamine concentrations had already built up to high levels in the body of specimens exposed to air for 144 h.

Glucose alleviates ammonia-induced inhibition of short-chain fatty acid metabolism in rat colonic epithelial cells

Ammonia decreased metabolism by rat colonic epithelial cells of butyrate and acetate to CO2 and ketones but increased oxidation of glucose and glutamine. Ammonia decreased cellular concentrations of oxaloacetate for all substrates evaluated. The extent to which butyrate carbon was oxidized to CO2 after entering the tricarboxylic acid (TCA) cycle was not significantly influenced by ammonia, suggesting there was no major shift toward efflux of carbon from the TCA cycle. Ammonia reduced entry of butyrate carbon into the TCA cycle, and the proportion of CoA esterified with acetate and butyrate correlated positively with the production of CO2 and ketone bodies. Also, ammonia reduced oxidation of propionate but had no effect on oxidation of 3-hydroxybutyrate. Inclusion of glucose, lactate, or glutamine with butyrate and acetate counteracted the ability of ammonia to decrease their oxidation. In rat colonocytes, it appears that ammonia suppresses short-chain fatty acid (SCFA) oxidation by inhibiting a step before or during their activation. This inhibition is alleviated by glucose and other energy-generating compounds. These results suggest that ammonia may only affect SCFA metabolism in vivo when glucose availability is compromised.

Ammonia neurotoxicity: role of the mitochondrial permeability transition

Hepatic encephalopathy (HE) is an important cause of morbidity and mortality in patients with severe liver disease. Although the mechanisms responsible for HE remain elusive, ammonia is generally considered to be involved in its pathogenesis, and astrocytes are thought to be the principal target of ammonia neurotoxicity. Altered bioenergetics and oxidative stress are also thought to play a major role in this disorder. In this paper, we present data invoking the mitochondrial permeability transition (MPT) as a factor in the pathogenesis of HE/hyperammonemia. The MPT is a Ca2+-dependent, cyclosporin A (CsA) sensitive process due to the opening of a pore in the inner mitochondrial membrane that leads to a collapse of ionic gradients and ultimately to mitochondrial dysfunction. Many of the factors that facilitate the induction of the MPT are also known to be implicated in the mechanism of HE, including free radicals, Ca2+, nitric oxide, alkaline pH, and glutamine. We have recently shown that treatment of cultured astrocytes with 5 mM NH4Cl resulted in a dissipation of the mitochondrial membrane potential (delta(psi)m), which was sensitive to CsA. Similarly treated cultured neurons failed to show a loss of the delta(psi)m. Further support for the ammonia induction of the MPT was obtained by observing an increase in mitochondrial permeability to 2-deoxyglucose-6-phosphate, and a decrease in calcein fluorescence in astrocytes after ammonia treatment, both of which were also blocked by CsA. CsA was likewise capable of exerting a protective effect against hyperammonemia in mice. Taken together, our data suggest that the MPT represents an important component of the pathogenesis of HE and other hyperammonemic states.

Carnitine metabolism in chronic liver disease

The liver is a central organ for carnitine metabolism and for the distribution of carnitine to the body. It is therefore not surprising that carnitine metabolism is impaired in patients and experimental animals with certain types of chronic liver disease. In this review, the changes in carnitine metabolism associated with chronic liver disease and the role of carnitine as a therapeutic agent in some of these conditions are discussed.